Electrophysiological anatomy of typical atrial flutter: The posterior boundary and causes for difficulty with ablation

Apoor S. Gami, William D. Edwards, Nirusha Lachman, Paul A. Friedman, Deepak Talreja, Thomas M. Munger, Stephen C. Hammill, Douglas L. Packer, Samuel J. Asirvatham

Research output: Contribution to journalArticlepeer-review

41 Scopus citations


Electrophysiological Anatomy of Typical Atrial Flutter. Background: The electrophysiological anatomy of cavotricuspid isthmus-dependent atrial flutter (CVTI-AFL) has not been fully elucidated. Methods: We studied 602 autopsied human hearts from individuals aged 0 to 103 years. We measured morphological features of the right atrium, including the crista terminalis (CT), pectinate muscles, sub-Eustachian pouch, Thebesian valve (TV), and the coronary sinus (CS) ostium. Results: In adults, the mean right atrium dimensions were 4.7 cm × 4.5 cm × 4.4 cm. Pectinate muscles extended medial to the CT in 54% of hearts. In 19% of hearts, these ended in another ridge termed the second CT. Pectinate muscles extended into the CVTI in 70% of hearts. A sub-Eustachian pouch was present in 16% of hearts, was always located on the septal CVTI, and was more likely when a prominent TV was also present. A TV, present in 62% of all hearts, covered the inferior quadrant of the CS ostium in 9% of these hearts. Conclusion: The posterior boundary of the reentrant circuit of CVTI-AFL comprises the Eustachian ridge and CT, but in some patients may also include a second CT. Sub-Eustachian pouches on the septal CVTI are strongly associated with a prominent TV. The lateral CVTI can have prominent pectinate muscles. This comprehensive characterization of the electrophysiological anatomy of the reentrant circuit of CVTI-AFL may provide guidance and improve success during difficult ablations.

Original languageEnglish (US)
Pages (from-to)144-149
Number of pages6
JournalJournal of cardiovascular electrophysiology
Issue number2
StatePublished - Feb 2010


  • Ablation
  • Atrial flutter
  • Cavotricuspid isthmus
  • Crista terminalis
  • Pectinate muscle
  • Right atrium

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)


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